Who are the MEs and what does the role require?

MEs across all services are experienced senior consultant grade doctors or an equivalent career grade (eg, associate surgical specialist trained abroad). Each service employed MEs from a range of medical specialties that were represented among the 20 interviewees: Acute/General Medicine (2); Anaesthesia (1); Elderly care (4); Emergency Medicine (2); Genitourinary Medicine (1); Intensive care (2); Obstetrics & Gynaecology (1); Orthopaedics (1); Palliative care (1); Pathology (4); Respiratory (1). Input from different specialties was regarded as beneficial in bringing different perspectives. Pathologists regarded themselves as more experienced in determining cause of death and dealing with coroners, whereas clinicians tended to view themselves as more focused on the care process. In specialties where death was more likely to be expected (eg, palliative or end-of-life care), the quality of care rather than avoidable mortality was regarded as a particular area of interest. It was considered important that the detection of potential problems in care by MEs should not focus solely on identifying issues implicated in the cause of death. The potential for inconsistency associated with different perspectives was raised.

There was consensus among interviewees that seniority, communication skills and confidence are key for the challenging questions and decisions required of MEs, as well as sensitive conversations with relatives. A number of MEs also commented that the role would not suit everyone who is eligible, thus highlighting the importance of the selection process. All MEs had completed the national online training package developed, which was regarded as a useful generic starting point that needed to be supplemented with more specific local training to familiarise MEs with local systems and internal pathways to refer cases for further review (eg, more detailed mortality review). The extent and nature of additional local training varied, but generally included shadowing and support from ME colleagues, and training events involving internal as well as external stakeholders (eg, coroners, registrars, hospital leads for mortality, safety, governance and bereavement services). Involvement of local stakeholders was regarded as helpful, as was the opportunity to attend national events to meet MEs from other services.

What does the ME review process involve?

Although the terminology varied (eg, screening, scrutiny), there was agreement that the ME review process was not a forensic review and was intended to identify ‘red flags’ or concerns that prompt referral to the coroner or internal governance systems for more detailed investigation and action as appropriate. ME services were delivering the core components of the ME role as identified in national guidance: screening of clinical notes, including review of other relevant records (eg, diagnostic tests); a discussion with the attending (usually junior) doctor responsible for completing the MCCD; a conversation with the bereaved relatives. At the time the interviews were conducted, the ME services were at different stages of development, reflecting incremental approaches to implementation of this new role and differences in the length of time they had been established. Therefore, not all hospital deaths were included in the full ME review process.

There was some variation between MEs in relation to the order in which they obtained information from attending doctors and medical records. Some of this was for pragmatic reasons (eg, availability of doctors). Specific approaches advocated within the ME service also contributed to variation, for example, one service had a more distinct differentiation between reviewing the cause of death and clinical governance review. MEs also expressed individual preferences about whether they reviewed the medical record or spoke to the attending doctors first.

Speaking to bereaved relatives was highly valued by interviewees across all services and was perceived to be valued by the relatives, who had the cause of death explained and were given the opportunity to ask questions and provide feedback on the care received. A script was used to guide these conversations in some services and was recommended as helpful for newer MEs. Information from relatives rarely changed opinions regarding the cause of death but did help identify potential quality-of-care issues within the hospital as well as the community setting (eg, care homes, ambulance service, primary care). Examination of the deceased was carried out by MEs involved in completion of cremation forms (a mandatory requirement) but was not considered informative in ME decision-making. It was difficult to establish a precise duration for the review process due to differences in the complexity of cases; approximately 30 min was most common and up to a maximum of 60 min to complete cremation forms or for particularly complicated cases.

In one service, a notable difference in the ME review process involved the delegation of specific tasks to MEOs with backgrounds in biomedical science and nursing. MEOs discussed cases with the attending doctors and spoke to the relatives. MEs reviewed the medical record and approved any decisions. Where appropriate, MEs spoke to attending doctors and relatives to explore or respond to specific concerns. Delegation to MEOs was regarded as beneficial in reducing the demand for ME time. In other services, MEOs provided administrative-based support only.

How do MEs act on potential quality-of-care problems?

When potential quality-of-care problems were identified, these were referred for further review to the coroner and/or internal governance systems. Coroner referrals were required when problems in care may have contributed to the death, whereas internal governance referrals occurred when the identified issues were unlikely to have contributed to the death but there appeared to be potential for organisational learning and improvement (eg, delays in escalation and transition to end-of-life care or omissions in recording). MEs identified variation in how they addressed potential governance concerns in coroner referrals, either simultaneously making a clinical governance referral or waiting for completion of the coroner review.

MEs identified various internal pathways to act on quality-of-care concerns, including clinical governance teams, RCRR, serious incidents, root cause analysis, morbidity and mortality meetings, clinical team review, and the Patient Advice and Liaison Service (PALS). The most consistent route for more detailed scrutiny was RCRR. Referrals for RCRR also included selected deaths mandated for investigation by the Learning from Deaths Programme. Some ME services were also asked by their hospital to refer certain deaths for further review, where they were a source of concern for the organisation (eg, a high number of deaths after myocardial infarction). Sometimes multiple pathways were used to simultaneously prompt further investigation and immediate action.

There appeared to be differences between MEs in the relative salience of information sources and the implicit criteria for referral decisions, which may influence consistency both within and between services. This was most notable in relation to the influence of information from relatives and in some instances appeared related to clinical specialty. Some MEs indicated that they had a ‘low threshold’ for RCRR referral based on relatives’ concerns, whereas others indicated that relatives’ concerns would be less likely to trigger referral for RCRR and tended to be referred to PALS. New referral pathways had been introduced to act on issues identified by MEs but considered not to merit RCRR, for example, direct feedback to clinical teams regarding concerns, as well as compliments from relatives. Local systems for documenting information also varied, though some services had learnt from other settings and adopted similar approaches.

How are ME services organised?

The need for ME services to integrate with existing administrative and clinical governance systems within each setting was identified as a source of variation. Ten of the services comprised a team of MEs working for a fixed number of hours or professional activities time each week. The majority of MEs also worked as doctors within their respective hospitals, except for one who was employed for ME-related work only. MEs avoided reviewing cases where they had clinical input. The numbers of MEs per service and number of hours worked varied, generally influenced by the number of deaths. Lead MEs were identified in a number of services, which involved a more strategic focus on the development of the service. None of the services operated out-of-hours except for relatively informal arrangements to expedite release of the body for religious or cultural reasons. Consequently, the ME caseload tended to be higher on Mondays.

Some services covered multiple hospitals and ensuring ME cover across different sites presented challenges, particularly where MEs could not be recruited on site. In one service, concern was raised about delays in accessing paper records where they had to come from another site. This impacted on the timeliness of clinical governance review and conversations with relatives. MCCDs could be completed without delay by attending doctors at the other site. Most of the hospitals used paper records but where electronic records were available they afforded greater flexibility over where and when MEs could review records.

The physical environment was identified as important, as was proximity to MEOs, administrative assistants and bereavement office staff. Administrative support was regarded as beneficial in helping MEs to manage their workload as sourcing and prioritising the notes, and arranging conversations with attending doctors and relatives, was often reported as time consuming and logistically challenging.

The way in which ME services were organised appeared to restrict opportunities for formal team communication, although some had developed approaches to facilitate more direct communication (eg, team meetings, social messaging platform). Feedback and learning were considered particular areas of weakness in most of the ME services. Specifically, the lack of structures for providing meaningful feedback to ‘close the loop’ on problems in care and clinical governance issues identified by MEs, and for sharing learning.

Service guidance and oversight were recommended to improve consistency across MEs but caution was also advised regarding the extent of standardisation, to avoid reducing the process to a ‘tick box exercise’.

How are ME services resourced?

The majority of MEs were funded via payments for completing cremation related tasks and paperwork, which in most services reimbursed MEs for their input. Other funding included limited Department of Health support for pilot services and from the hospitals. One service was delivered by a sole ME operating in a voluntary capacity pending the appointment of staff for a fully resourced service.

Cremation fees placed constraints on service resources by restricting the ability of MEs to hand over unfinished cases. The same doctor had to complete all components of the ME role plus examine the deceased to meet cremation form requirements. Similarly, these requirements prevented the delegation of ME activities to MEOs as they had to be carried out by a doctor. Variation in funding was identified within services. For example, where there was no ME on-site, the reviews of deaths were funded by the hospital as MEs were unable to meet the cremation form requirement to examine the deceased. Employment by the hospital and funding of ME services by the hospitals in which they are located was not in itself regarded as compromising the independence of MEs. Some MEs referred to their duty of candour as doctors and professional accountability as safeguarding the independence of their practice.

A degree of flexibility in ME availability was identified as necessary to accommodate both fluctuating demands and cremation form requirements. The demands of consultant rotas and role requirements, particularly in some specialties, made this challenging. The availability of staff in supporting roles across service office hours provided continuity and their ongoing availability appeared to be as important as MEs in ensuring continuity of service. Examples were identified in two services where shortages of MEOs and bereavement office staff restricted ME service delivery.